The United States military is the largest in the world. Ensuring that more than one million service members build the requisite knowledge, skill, and proficiency they will rely on in life-or-death situations is a considerable challenge.

Some of the most critical training for the Department of Defense (DOD) is how to train soldiers and medics to attend to trauma patients during wartime.

After Operation Desert Storm, shortcomings were revealed by the U.S. GAO on survivability and trauma care for soldiers in this theater. The DOD saw a need to collect combat trauma data for gap and trend analysis in order to use that data to improve outcomes.

In 2006, the DOD Joint Trauma System (JTS) was instituted and its mission was to:
     • provide evidence-based Performance Improvement (PI) of trauma and combat casualty care
     • reduce morbidity and mortality to the lowest possible levels
     • provide evidence-based recommendations on trauma care and trauma systems

In order to understand why the JTS was envisioned and built, it is helpful to know how the continuum of medical care is provided in a war zone.

The military has established specific levels of care each with a specific purpose in the treatment continuum that extends from the battlefield to the most advanced military treatment facility.

Care begins at the point of injury, in the field, attended by either another service member or a medic. If injuries require further care, the injured are evacuated away from the battlefield but still are receiving field-based urgent care. If more care is needed, trauma cases are evacuated to a field hospital. Lastly, cases are sent to a fixed facility hospital such as Germany or the U.S. by plane or ship.

At each step of the continuum of care, information must flow from one treating partner to the next.When training new recruits on how to assist the injured on the battlefield and throughout the continuum of care, protocols and checklists (while sound) are not completely adequate.

As with all things military, there is a protocol for Tactical Combat Casualty Care (TCCC) known as MARCH. It is a simple acronym for remembering the necessary steps in priority for saving lives in combat. M-massive hemorrhage, A-airway, R-respiratory, C-circulation, and H-hypothermia. These are all leading causes of preventable death on the battlefield. However, algorithms and protocols can suffer when actual injured human beings are added to the mix.

Imagine being a 20-year-old first-time medic in your first battlefield experience. All your training can hinge on split-second decisions with a variety of outcomes. And most importantly, humans don’t always present in the same fashion, and the wounded can deteriorate and decompensate quickly.

Prolonged casualty care requires critical thinking – you have a problem and you have a variety of interventions, what do you do? While the algorithms are helpful, they don’t replace or foster critical thinking skills in one of the worst environments young people can experience.

Another complicating factor is today’s engagements are taking place in more unstable environments. In a model where the U.S. military in prior engagements might have had a “front line”, total air superiority, and even trauma centers in-country, the Pentagon is preparing today’s fighting forces for “near-peer” fighting in large-scale and dispersed operations. That is especially true for the medics who will be tasked with caring for the injured for longer periods of time across the continuum of care in unstable conditions.

For military medics, this scenario requires a new kind of training, new equipment, and a new approach to casualty care. The DOD knew something had to change.

Building a New Generation of Patient Simulators for Combat Care on the Battlefield

Existing training using static patient simulators had been the de facto standard but it wasn’t enough. Female simulators weren’t an option, for one thing. Existing simulators that were built to withstand rugged environments were low fidelity and lacking in the necessary clinical capabilities for comprehensive TC3 training; while existing high-fidelity simulators were not robust enough and were expensive.

A Small Business Innovation Research (SBIR) grant program was developed to see if the vendor community could help the DOD build a better patient simulator solution. The simulators needed to be high fidelity with realistic male and female versions; allow for multiple scenarios that could take place due to the changing engagement realities, and be long-lasting and rugged.

The Operative Experience, Inc. (OEI) leadership team knew that advances in technology in other fields could completely change the way simulators could be built and deployed.

OEI’s goal was to establish a modern, very flexible and adaptable technology that can transform and can grow further based on applications that are built and installed on the simulator “chassis”. While the original effort of building the platform was an investment, value comes with the ability to use that solid platform for growth. The underpinnings of the platform don’t have to be redone every time a change is needed or made. A simple smart module can be written that can ride on the platform. Armed with this vision, the Tactical Trauma Care Pro Simulator was born.

The Tactical Trauma Care Pro Simulators are a suite of the world’s most lifelike and anatomically accurate, fully-modular, high-fidelity, male and female simulators for comprehensive TCCC and medical provider-level care training.

With lifelike soft tissue and skin, advanced physiology and clinical conditions, drug support, integrated patient monitoring, automated expert-validated clinical scenarios, and on-the-fly, instructor-driven scenarios, the simulators are truly the next level in experiential learning.

The TCCS Pro has been developed with Smart Limbs that have fully interchangeable trauma wound configurations with software designed to automatically adjust to specific limb features. In other words, when you attach a smart limb to the chassis, the simulator automatically reconfigures itself for that wound presentation. One simulator can be transformed from a patient with no visible trauma wounds to a polytrauma patient in a matter of minutes.

OEI also made sure the simulators are ruggedized, water-resistant, fully mobile, and with over 72 hours of battery life, they are ideally suited for challenging training scenarios in real-world, indoor, and outdoor environments. With tablet-based, touchscreen software control, the simulators are easy to use for teachers and students and easy to manage for learning departments. OEI Pro series simulators meet and exceed, like no other simulators, all of the latest DOD training needs and requirements.

Outcomes for female soldiers are also an important part of the equation. The number of women serving has risen dramatically since 2015. Women among the enlisted ranks has increased seven-fold, from 2% to 14%. The DOD found that while the percentage of casualties for females were low (around 17%), those casualties suffered from a lower survivability rate than their male counterparts.

OEI’s Female Mannequin approach was not to simply turn a male mannequin into a female. It was built on specifications of an actual female body provided by the DOD resulting in the world’s first 100% anatomically correct, fully instrumented, smart female trauma care simulator.

“Having an anatomically correct female is a great advantage to training. We try to make training as real as possible to desensitize folks. If we can train medics to completely expose a female mannequin in a scenario, they are more likely to do so in the field.“
– Walter Engel, Chief Consultant, Chiral Medical Consulting

Using the TCCS Pro across the continuum of care was important in order to provide a realism previous stand-alone simulators could not match. Because the TCCS Pro is ruggedized with the longest-lasting hot-swappable batteries in the industry, the simulator is able to be conveyed through the various evacuation routes with interventions. OEI Pro Series simulators are the only simulators capable of non-stop running beyond 72 hours – the minimum PCC training time.

Walter Engle continues:
“The simulators can provide you feedback. Heart sounds, lung sounds, eye movement, all that. We ask a lot of our 18 year old medics doing triage in the dirt. This flows right into their critical thinking skills.”

OEI continues to refine and expand its suite of offerings for the simulators. OEI is currently working on advanced telemedicine procedures, moving patients to minimize decubitus ulcers and other specialty interventions are on the way.

Remember all that data that needed to flow with the patient throughout the continuum of care? This is another area that OEI’s innovation is supporting and assisting the DOD.

During treatment, each injured servicemember receives a TC3 card which is the data around their injury, how it happened, signs and symptoms, and treatment. This card follows the injured along the continuum of care in order to have a complete picture of what was done. That data is then entered (after the fact) into a computer system that is used to provide insight into treatment and outcomes.

OEI has succeeded in digitizing the card for inclusion into the TCCS Pro simulators. As the student is doing interventions, the simulator does the timestamps and gives the instructor a document for after action reviews.

A second card allows the student to fill the card out without it being auto-populated. This enables the instructor to discuss and review the learner’s impressions versus what is hardcoded by the simulator – a great teaching tool.

The future of the TCS Pro for the Department of Defense will also include the ability to train transitions to civilian care. Hospitals within the DOD system will eventually join in using the TCCS Pro.

As far as civilian care goes, rural hospitals and EMS providers are using this same TC3 data collection model, so OEI’s reach will spread much wider than just the Department of Defense. Military care emergency management services, Department of Homeland Security, and FEMA have all adopted TECC Tactical Emergency Critical care. The simulators can also be used to teach and certify CPR training.

OEI’s newest revolution in trauma simulators were developed specifically to meet the demanding training protocols of the Department of Defense, for both male and female soldiers. With realism, fidelity, and the ability to engage across the continuum of care, the OEI TCCS Pro simulators will be instrumental in boosting critical thinking skills and perfecting lifesaving skills on the battlefield.